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Home
About Us
Why Us
Meet Our Team
NIHB (First Nations)
for patients
Your First Visit
new patient
Financial Options
downloadable form
Parent FAQs
procedures
general & family care
check-ups & cleanings
oral cancer screening
restorative care
Dental Implants
dentures
crowns & bridges
metal-free (tooth-coloured) fillings
bone grafting
Cosmetic Care
porcelain veneers
Teeth Whitening
gum recontouring
Orthodontics
invisalign
Children’s Dentistry
sealant & fluoride treatment
dental cavities
mouth guards
space maintainers
Parent FAQs
Gum Disease & Bad Breath
periodontal treatment
halitosis treatment
Additional Care
sedation dentistry
TMJ treatment
Urgent Dental Care
root canal therapy
extraction & wisdom tooth removal
Emergency
Cases
Blog
Contact Us
covid 19 screening form
Pay Now
X
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Covid 19 Screening Form
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Name
Phone
Email
Do you have a fever or have felt hot or feverish anytime in the last 10 days?
Yes
No
Do you have any of these symptoms?
New or worsening cough
New or worsening shortness of breath
Difficulty breathing
Sore throat or painful swallowing
Runny nose
None of the above
Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? (Healthcare workers who have worn appropriate PPE may answer No)
Yes
No
Have you returned from travel outside of Canada in the last 14 days?
Yes
No
Have you returned from travel within Canada from a location known affected with COVID-19 in the last 14 days?
Yes
No
Is your workplace considered high risk?(Healthcare workers who have worn appropriate PPE may answer No)
Yes
No
Are you over the age of 65?
Yes
No
Do you have any of the following?
Heart Disease
Lung Disease
Kidney Disease
Diabetes
Any auto-immune disorder
None of the above
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